Interactive: Texas Medicaid Caseload and Premium Costs

It’s Texas Medicaid’s time in the limelight. Federal health care reform calls for expanding it dramatically. Some Republicans are angling to bag the program altogether. And lawmakers, facing a massive budget shortfall, are gearing up for a tense debate over broadening the reach of cost-cutting Medicaid managed care plans into rural counties and the long-protected Rio Grande Valley.

Often lost in these conversations? The people Medicaid covers and the money Texas pays to cover them. Our interactive allows readers to visualize the 3 million people served by Texas Medicaid and the roughly $6 billion Texas spends on Medicaid managed care premiums every year, broken down by patient eligibility, region and type of payment plan.

Children make up the overwhelming majority of Texas Medicaid recipients; more than 2 million of them are covered in any given month. The state spent $2.7 billion in the last fiscal year on the managed care plans that cover 1.7 million of them.

The second largest group insured by Medicaid is 350,000 eligible seniors, followed by 330,000 people with disabilities, 210,000 newborns and 130,000 pregnant women. Impoverished adults, are the smallest Medicaid eligibility group; fewer than 100,000 are insured in a given month.

As lawmakers debate adjustments to Medicaid, they’ll consider the cost per patient, which differs based on the patient’s eligibility type, location and payment program.
Children are by far the least expensive to insure. Their health care premiums in the state’s STAR managed care plan average $110 a month. By comparison, STAR+PLUS premiums for disabled people requiring long-term care average $3,200 a month.

Across Texas’ regions, children are always the least expensive to cover, and people requiring long-term care are always the most expensive. But the price of covering each group ranges enormously. For example, STAR premiums for newborns averaged $790 per month in Nueces County in the last fiscal year, but only $395 in Lubbock County. Conversely, Lubbock County had the highest average STAR premium for pregnant women ($835 per month), while El Paso County had the lowest ($415). Disregarding eligibility type, Nueces County had the highest average STAR premium cost per month in fiscal year 2010 ($235), and El Paso had the lowest ($155).

How much it costs to care for Texas Medicaid patients also depends on the health care plan they’re enrolled in. Most of Texas’ Medicaid patients are enrolled in managed care, in which private health insurance companies contracted by the state set premiums based on a patient’s eligibility type and region. The first and most common state managed care program, STAR, serves only urban counties — Bexar, Harris, Dallas, El Paso, Lubbock, Nueces, Tarrant and Travis. Medicaid clients in these regions can select an HMO approved by the state to coordinate their medical services. STAR+PLUS is an extension of STAR that covers acute and long-term care for seniors and disabled persons in six of the above-mentioned urban counties. STAR+PLUS clients are divided into two categories — those who require long-term care, and everybody else.
An alternative way to pay for Medicaid recipients’ health care — and the only way in regions with no managed care — is through fee-for-service payments. Under the fee-for-service model, the state directly reimburses medical providers who accept Medicaid clients.

Bridging the gap, in 2005, the state expanded Medicaid managed care coverage to non-urban regions in the form of Primary Case Care Management, or PCCM. Unlike STAR and STAR+PLUS, there’s no fixed price for PCCM services. Clients choose a primary care provider, which the state reimburses with fee-for-service payments and a monthly case management fee of $5 to $14, depending on the risk group. Urban regions without STAR+PLUS — Dallas, Tarrant and Lubbock counties — also use PCCM to cover disabled recipients.